Written evidence submitted by NHS Providers [SRF 005]

 

NHS Providers is the membership organisation for the NHS hospital, mental health, community and ambulance services that treat patients and service users in the NHS. We help those NHS trusts and foundation trusts to deliver high-quality, patient-focused care by enabling them to learn from each other, acting as their public voice and helping shape the system in which they operate.

 

NHS Providers has all trusts in voluntary membership, collectively accounting for £87bn of annual expenditure and employing more than one million staff.

 

Our evidence will focus on the following issues set out in the Terms of Reference:

Key points

 

 

 

The approach the Government should take to local government funding as part of the 2020 Spending Review and what the key features of that settlement should be

 

1.       Cuts to local government funding in recent years have put councils under significant financial pressure. Recent figures from the Local Government Association (LGA) estimate that councils could face a funding gap of £5.3 billion by 2023/24 which could increase to £9.8 billion due to uncertainty around the impact of COVID-19[1]. Key features of the one-year funding settlement should be adult social care funding, public health services and community health services (commissioned by local authorities).

 

2.       Adult social care has been under increasing pressure in recent years, with analysis from the LGA prior to the pandemic estimating that adult social care costs were projected to increase by £1.3 billion each year from 2019/2020 to 2024/25 just to maintain 2019/2020 levels of access[2]. The social care sector requires a short-term cash injection over the winter period. The Association of Directors of Adult Social Services has called for the government to provide £480 million of winter funding for social care to help fund increased demand for domiciliary care[3] and maintain flow across the health and care system. However, it is vital that the government also comes forward with a meaningful multi-year settlement for the social care sector; without a long term funding plan it is extremely challenging for local authorities to make improvements and plan for the future, resulting in further instability for the social care sector.

 

3.       There should be no further risk of cuts to public health funding nationally, or locally, in the 2020 Spending Review. The central government public health grant has been reduced by £531 million between 2015/16 and 2019/20[4]. This has a direct impact on how much local authorities spend on public health, negatively impacting on their ability to deliver prevention and early intervention services and hampering their ability to address inequalities across the wider determinants of health. In 2017/18, 85% of councils reported reducing their spending on core public health services and like-for-like spending on public health services was 8% lower in 2017/18 compared to in 2013/14.[5]

 

4.       COVID-19 has also highlighted the essential role played by local public health systems in health protection and disease control and the need for the UK to learn from the infrastructure some other countries had in place with regard, for example, to testing. The experience of the pandemic thus far has highlighted the need to deliver an appropriate balance between nationally supported activity, and investment in local, specialist teams who are often better placed to work with local communities on health protection and public health issues.  As we move through the next phase of the pandemic, it is crucial that local authorities are equipped with sufficient funding and capacity to enable them to cope with increased demand on public health services both to address the wider determinants of health, and to better invest in managing the risks presented by a pandemic. 

 

 

Long term funding for social care and wider reform – on a cross-party basis 

 

5.       Reform to place social care on a sustainable footing is long overdue and is now more urgent than ever in the context of the COVID-19 pandemic. Successive governments have failed to respond to calls for social care reform and following a decade of numerous commissions, reviews and the much delayed social care white paper, it is vital that political parties work cross party to ensure that social care is placed on a sustainable footing as soon as possible.

 

6.       There is widespread agreement that social care funding must increase to meet changing demographic needs. The Health and Social Care Committee recently concluded that social care funding would need to increase by £7 billion per year by 2023/24 to cover demographic changes, competitive pay and protection against catastrophic costs[6]. There is also a broad consensus that the social care system needs to be reformed into a more fair and accessible system which provides care to those who need it.

 

7.       There are a number of options for funding an increase in the adult social care budget, including changes to tax contributions, a social care premium, and changes to the self-funding model. The merits and drawbacks of these have been explored at length across numerous publications in recent years. The choice of which option to pursue is ultimately a political decision for the government to take and should be discussed in an open public debate.  We note however that numerous reviews over the past decade have provided a sound foundation, costed options and the evidence for this decision to be made relatively swiftly.

 

8.       We cannot continue to view social care in isolation from the NHS, as we need both systems to be properly funded and functioning effectively to ensure that all individuals with care needs can be supported to live independently and stay well in the community. This means that financial and wider reform of the social care system must consider the views of trusts and colleagues across the wider health and care system.

 

9.       Any settlement for adult social care should meet the principles set out by the Health for Care Coalition, of which NHS Providers is a member[7]. The Coalition has also published three recommendations which are critical to achieving a long-term settlement for social care:

 

  1. Eligibility should be based on need and must be widened to make sure that those with unmet or under-met need have access to appropriate care and support
  2. We need a workforce strategy which encompasses health and care, tackles the recruitment and retention crisis in the sector, and addresses the serious inadequacies in pay, training and career progression for social care staff
  3. We need a set of measures to support unpaid carers which recognises their huge contribution to the economy
  4. The Government must seek to build stronger ties between the health and social care sectors, and between them and the wide array of community, voluntary and third-sector providers

 

 

What the impact is of another one-year spending review and a further delay to a multi-year settlement and the Fair Funding Review

 

10.   Social care and health care are highly interdependent, and each plays a key role in ensuring that people are supported in the right setting at the right time. A survey conducted by NHS Providers in October 2019 shows that over 90% of trust leaders cite underinvestment in their local social care partners as a key cause for concern[8]. Underinvestment in local authority care budgets, increased demand and sustained pressure on care providers has a knock-on impact on vulnerable people deteriorating and needing increased support from health services. For example, a briefing issued by Alzheimer’s Society in January 2020 showed the strain on the NHS of people with dementia ending up in hospital due to insufficient care support packages and care home places[9].

 

11.   The government’s decision to conduct a one-year spending review rather than a multi-year review will hinder the ability of the NHS and the social care sector to plan services on a long-term basis, which curtails service improvements and investment in innovative delivery models. A further delay in delivering a multi-year settlement is likely to exacerbate fragility in the social care sector, with care providers already facing financial challenges due to the introduction of the national living wage, a drop in new residents (as people choose to remain at home due to COVID-19 transmission fears) and other COVID-19 cost pressures.

 

12.   In addition, underfunding and poor access to social care provision has a direct impact on delayed transfers of care (DTOCs) in the acute and community sectors. DTOCs occur when patients who are ready to be discharged to another care setting are unable to do so, because the support package or funding is not in place. This includes patients who are waiting to be transferred to a residential home, nursing home, or to their own home with a care package. In February 2020, there were 155,717 delayed days, equivalent to 5,370 daily beds occupied by a patient who was delayed in transferring, an increase of 22.4% when compared to February 2019[10]. This was the highest level of DTOCs since November 2017 and is in line with other operational pressures across the health and care system. While the majority of these delays were NHS transfers, just under a third were due to an inability to access social care packages. If discharge to assess funding is not made permanent in the Spending Review, discharge flow will begin to slow down and DTOCs will start to creep back into the system (see paragraphs 15-18).

 

13.   While DTOCs in the acute sector are well documented, cuts to social care provision equally impact other parts of the NHS provider sector, including community, mental health and ambulance trusts –all of which would benefit from appropriate investment in preventative support in the community, and all of which face additional pressures as they seek to be responsive to the needs of people who could be best supported by social care services. In its February 2018 report on the adult social care workforce, the National Audit Office found that one fifth of emergency admissions to hospital were for existing conditions that primary care, community or social care could manage[11].  

 

14.   Unnecessarily prolonged hospital stays can damage patients’ health and wellbeing, increasing the chance of bed ulcers and falls, prompting muscle wastage if patients cannot regain their physical independence, and impacting their mental health. Delayed discharges put pressure on the health and care system as they restrict the ‘flow’ of patients needing medical treatment through the system. Although trusts work closely with their local partners to integrate health and care services, prior to COVID-19 there were regulatory, funding and capacity barriers to discharging patients to social care or community rehab settings quickly. Such delays and avoidable admissions have a substantial impact on patients and trusts. The National Audit Office estimated that the gross annual cost to the NHS of keeping older patients in hospital who no longer need to receive acute clinical care is around £820m[12].

 

Discharge to assess

15.   During the first wave of the pandemic, the NHS rapidly implemented a new “discharge to assess” model, which saw community providers and local partners working together to ensure those patients who were medically fit could be discharged into the community, enabling the NHS to free up capacity for the most critically ill COVID-19 patients. The removal of regulatory and funding barriers (thanks to the suspension of NHS Continuing Healthcare (CHC) assessments and accompanying national funding of care packages) during the first wave of the pandemic allowed the safe discharge of thousands of medically fit patients.

16.   However, recent reports suggest that there have been growing delays in discharge processes and increasing numbers of ‘super stranded’ patients in the last couple of months. While there are several complex factors at play, providers report that the reintroduction of CHC assessments (from 1 September 2020), and the introduction of more complex discharge requirements, including the need to designate isolation facilities for those discharged to care homes (from 16 October 2020), have contributed to these issues with patient flow.

17.   Trusts and their partners would welcome a further suspension of CHC to free up much needed nursing staff to help manage the second wave of the virus which is coinciding with normal winter pressures. Also, while new discharge requirements are well-intentioned, there are clearly challenges with implementation which need to be worked through urgently with the sector. Funding for the discharge to assess policy must be made permanent to maintain patient flow and hospital capacity, as well as to bring about a cultural and structural shift to a ‘home first’ model. Without a long-term financial settlement for local authorities, there will be knock on impacts for the quality of patient care and capacity issues in hospitals.

18.   A potential lack of social care capacity, in part related to the reintroduction of CHC and new discharge requirements, could result in an increased number of DTOCs, placing yet more pressure on the NHS and depriving trusts of both general and acute and intensive care bed capacity which could be used to treat patients suffering with COVID-19.

Retendering of community health services 

 

19.   Further delays to a long-term funding settlement for social care risk decimating community and public health contracts even further. Local authorities face a growing income shortfall for 2020/21, which is only partly covered by emergency COVID-19 funding[13]. As local authorities have a legal requirement to balance their books, without rapid notice of where the remaining funding is coming from in year, they will have to start identifying savings. NHS trusts believe significant cuts to community health and public health services commissioned from the NHS will inevitably follow, together with further pressure on already stretched social care services.

 

20.   Some local authorities are already looking to retender contracts for NHS community health services amid the COVID-19 pandemic. We believe that competitive tendering at this time is a distraction and risks demoralising and destabilising a considerable section of the NHS workforce, and destabilising services for patients. Some trusts report that launching the retendering process during such great operational pressures will mean that some providers will be unable to participate or even have to hand back contracts.

 

21.   The Community Network, supported by NHS Providers and the NHS Confederation, wrote to the Secretaries of State for the Department of Health and Social Care and the Ministry of Housing and Local Government in June[14] to raise concerns about the impact any retendering could have on community providers and local partners who are working hard to provide aftercare to those who have suffered with COVID-19 as well as restarting non-COVID services, coping with a second wave and preparing for traditional winter pressures. In the letter we called for the government to implement a pause on retendering NHS community services contracts until the end of 2021/22 to allow services and staff the time they need to recover. The pandemic has exposed how neglected our public health infrastructure is and we believe that putting public heath contracts out for retender at this time is inappropriate.

 

22.   We understand the financial pressures on local authorities at the current time.  However competitive retendering does not reflect the spirit of collaborative working during the COVID-19 response. Some cash-strapped local authorities have found pragmatic ways to avoid retendering community services and destabilising good relationships between the NHS and local authorities.

 

23.   In addition, community service providers (including trusts, community interest companies and other social enterprises) are still waiting for a national commitment to fully fund the Agenda for Change pay uplift and pension costs for staff employed on NHS contracts through health services now commissioned by local authorities. Previous uplifts to public health grants were welcome but do not meet the uplift required on many community health services contracts which are multiyear, fixed price and not open for renegotiation. Some local authorities have even held back the Agenda for Change uplift as there is no requirement to ringfence this funding. Some community providers are considering withdrawing from NHS contracts they consider to be unsustainable because of these problems. In advance of the new pay settlement, there needs to be a long-term solution to stabilise these key NHS services.

 

Conclusion

 

24.   Years of cuts to local authority budgets are placing significant pressure on our social care and public health systems and the wider NHS. COVID-19 has revealed the fragility of the social care sector and highlighted the urgent need for long-term reform and a sustainable funding settlement. The absence of a multi-year spending review risks exacerbating the instability faced by social care providers and will have a detrimental impact on the ability of councils to deliver vital public health provision. Addressing both the short and long-term impact of the pandemic on our communities will require local authorities to be properly funded and supported – without sufficient investment in local services, demand on NHS services will undoubtedly increase, placing yet more pressure on trusts and frontline staff at an extremely challenging time for the health and care system.

 

November 2020


[1] Comprehensive Spending Review 2020: LGA Submission, Sept 29 2020

[2] Comprehensive Spending Review 2020: LGA Submission, Sept 29 2020

[3] ADASS Statement: Why the Government must prioritise adult social care this winter, November 2020

[4] LGA, Parliamentary Briefing, May 2019

[5] The King’s Fund, Spending on public health, December 2018

[6] House of Commons, Health and Social Care Committee, Social Care Funding and Workforce report, October 2020

[7] NHS Confederation, Health for Care

[8] NHS Providers, State of the Provider Sector, October 2019

[9] Analysis of NHS England’s hospital episode statistics dataset 2012/13 to 2017/18, Alzheimer’s Society, 22 January 2020

[10] NHS England, Delayed Transfers of Care Data 2019-20

[11] National Audit Office, Adult social care in England, February 2018

[12] National Audit Office, Discharging older patients from hospital, May 2016

[13] Comprehensive Spending Review 2020: LGA Submission, Sept 29 2020

[14] Letter from the Community Network, June 2020